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Webinar on “Mental Health and the Sustainable Goals
2030: Exploring potential, Achieving Health for All”
Welcome and Introduction
Maria Nyman, Director
Mental Health Europe
Who we are, what we do
▶We are a European umbrella organisation
▶Advocating for the rights of people with mental health problems
▶Representing +73 members across 30 European countries
▶Active in the field of mental health and in European institutions
since 1985
▶Our members are mental health professionals, national
organisations, services-providers, users & ex-users of services,
family organisations…
▶Not funded by the pharmaceutical industry
Strategic priorities
Human-rights based & recovery
Ensure a human rights–based and recovery-
centered approach to mental health
Parity of esteem
Valuing mental health equally with physical
health
Community based care
Advocate for deinstitutionalisation and for better
community based care
Mental health at work
Promote for better mental health at work
Mental Health & the SDGs
Goal 3: Ensure healthy lives and promote
well-being for all at all ages
“Ensuring healthy lives and promoting the well-being
for all at all ages is essential to sustainable
development.”
Nicole Votruba, Coordinator
FundaMentalSDG
Webinar Mental Health Europe
Mental Health and the Sustainable
Development Goals 2030
Nicole Votruba,
King’s College London
FundaMentalSDG Co-ordinator
Outline
1. What is FundaMentalSDG?
2. What are the SDGs and how are they relevant
for mental health?
3. How can States promote and implement
mental health through the SDGs?
What is
FundaMentalSDG?
2015
Sustainable Development Goals (SDG)
11
2000
Millennium Development Goals (MDGs)
No longer can we look away. By Robin Hammond
FundaMentalSDG
A global initiative to strengthen mental health in
United Nations Sustainable Development Goals
www.FundaMentalSDG.org
• Barbados
First, as the world is thinking about a development
framework to build on the Millennium Development
Goals, we need to place mental health in general
and depression in particular within the post-2015
agenda.
Kofi Annan
Economist Group's Global Crisis of Depression Conference
London, 25.11.2014
What are the SDGs and
where is mental health?
17 Goals
232 Indicators
169 Targets
Mental Health
SDG Declaration Preamble
Mental health is a development priority (§ 7, §26)
SDG Goal 3 (Health) targets
• Prevention, treatment & promotion of mental health (3.4)
• Substance abuse (3.5)
• Universal health coverage (3.8)
Mental health cross-cuts the SDGs
1. No single mental health goal, only targets &
indicators: Risk of weak commitment
2. No indicator to include people with severe mental
disorders
3. Mental health crosslinks of the SDGs risk to be
ignored
Challenges
How can States promote
and implement mental
health through the SDGs?
Indicators Measure the SDG progress
Target 3.4 By 2030, reduce by one third premature mortality from non-communicable
diseases through prevention and treatment and promote mental health and well-being
3.4.2 Suicide mortality rate
Target 3.5 Strengthen the prevention and treatment of substance abuse, including
narcotic drug abuse and harmful use of alcohol
3.5.1 Coverage of treatment interventions (pharmacological,
psychosocial and rehabilitation and aftercare services) for
substance use disorders
3.5.2 Harmful use of alcohol, defined according to the national
context as alcohol per capita consumption (aged 15 years and
older) within a calendar year in litres of pure alcohol
Indicators for mental health (SDG 3)
Considerable challenges for many countries and organizations
• Aligning national indicators to the 2030 Agenda
• Integration, operationalisation, measurement, evaluation, reporting
Many countries are putting in place initiatives to advance
implementation
UN recommendations, guidelines and best practices
• UN Division for Sustainable Development (DSD)
• High-Level Political Forum
• UN Partnerships for SDGs online platform
Implementing the SDGs
27www.sustainabledevelopment.un.orgwww.undg.org
www.undg.org/2030-agenda/mainstreaming-2030-agenda/tailoring-sdg-to-national-context/
www.undg.org
Funding & investment potential
Charlson FJ, Dieleman J, Singh L, Whiteford HA (2017) Donor Financing of Global Mental Health, 1995—2015: An Assessment of Trends, Channels, and Alignment with the Disease Burden. PLoS ONE 12(1): e0169384. doi:10.1371/ journal.pone.0169384
MDGs SDGs
Comparison of major health focus categories receiving development assistance
Prioritise mental health, beyond the SDGs
• Include people with severe mental disorders
• Considering mental health crosslinks
• UN member states already committed to comprehensive WHO
Mental Health Global Action Plan 2013-20 (no additional effort)
Contact
Nicole Votruba
Institute of Psychiatry, Psychology & Neuroscience
King’s College London
www.fundamentalsdg.org
@NicoleVotruba
Dainius Pūras, Special Rapporteur on the right of
everyone to the enjoyment of the highest attainable
standard of health
United Nations Human Rights
Mental Health and the Sustainable
Development Goals 2030: Exploring
Potential, Achieving Health for All
Dainius Pūras
UN Special rapporteur on the right to health
MHE webinar, May 2, 2018
UN RIGHT TO HEALTH MANDATE
• Mandate established in 2002. Paul Hunt (2002-2008), Anand Grover (2008-2014), Dainius Puras(2014 -). The mandate is a part of UN Special procedures mechanism
• UN Special procedures mechanism: Mandate holders are appointed by UN Human rights council. They are independent experts. They do not have job contract with UN. They inform UN and Member states about challenges, obstacles, opportunities and recommend how to move to full realization of human rights
• Primary Objectives: – Promote and clarify right to physical and mental health
– Identify challenges and good practices
– Inform member states and other stakeholders
• Not right to be healthy, but right to the enjoyment of the highest attainable standard of physical and mental health
• Not just right to medical care (AAAQ), but also determinants of health – such as poverty, violence, discrimination
• Working methods: thematic reports, country missions, communications
RIGH TO HEALTH - ANALYTICAL FRAMEWORK(1)
• States must comply with national and international human rights laws, norms and standards.
• States must act to progressively realize the right to health over time. Full realisation of the right
requires sufficient resources. But States must make progress, have a plan, benchmarks and indicators.
• Some obligations – such as the duty to avoid discrimination - must be put into effect immediately.
• Health services, goods and facilities must be available, accessible, acceptable, and of good quality
(AAAQ).
• States must recognize both freedoms and entitlements about health – for example, freedom from
discrimination and entitlement to decent food, clean water and sanitation, healthy environment
RIGHT TO HEALTH - ANALYTICAL FRAMEWORK(2)
• States have duties to respect, protect and fulfill the right to health – a) states must actively do things
to ensure people can enjoy their right to health, b) not to do things which interfere with people’s
right to health, c) must stop others interfering with people enjoying their right to health.
• Special attention must be given to issues of non-discrimination, equality and vulnerability. These
are issues that are central to ideas of human rights, and they are crucially important for realization of
the right to health.
• Individuals and groups must be able to take part in designing services that are for them, and in the
development of policies that affect them (principle of meaningful participation)
• States have right-to-health obligations around international assistance and co-operation.
• States must have effective, transparent and accessible mechanisms for monitoring and accountability
around the right to health, and, in turn, are accountable to the international community.
WAY FORWARD: CHALLENGES AND OPPORTUNITIES IN
ADDRESSING CROSS-CUTTING ISSUES
• Transition from Millennium Development Goals (MDGs) to Sustainable Development Goals
(SDGs). Agenda 2030 – equally important to all regions, including Europe. Non-communicable
diseases (NCDs), including mental health conditions – now are in the centre of health-related
policies
• To leave no one behind – the principle of non-discrimination. Human rights in patient care
• Life cycle approach – right to health in early childhood, adolescence; healthy workplace, healthy
aging
• Mental health and emotional well-being - all activities should be integrated in general healthcare
• Universal health coverage. Primary care and preventive/social medicine as cornerstone of
sustainable and effective healthcare systems. Alma Ata (1978) and Ottawa (1986) - need to be re-
vitalized. Health in all policies
• Rational and transparent use of specialized medicine and biomedical interventions. Expensive
biomedical technologies and “vertical” programmes for treatment of certain diseases should not
dominate in health policies. “Choosing wisely” initiative
• Syndemics - an understanding of disease that focuses on the complex interconnections among co-
morbid diseases, biological linkages, and interacting social and environmental conditions.
“The human rights framework provides a more useful approach for analyzing and
responding to modern public health challenges than any framework thus far
available within the biomedical tradition.”
Jonathan MannHealth and human rights, HIV/AIDS physician and advocate
Agenda 2030 and SDGs
• Differences between MDGS and SDGs. SDGs are important to all
regions; they address physical and mental health.
• Agenda 2030 is grounded in the UDHR (1948)
• SDGs and targets are integrated and indivisible, they balance the 3
dimensions of sustainable development – economic, social,
environmental
• SDGs are global in nature and take into account national realities
• Ensure that no one is left behind – human rights and equality/non-
discrimination imperative
Agenda 2030 and SDGs
• SDGs seek to achieve gender equality
• Right to health is not just about Goal3. Many other goals are closely linked to health
• Health is central to SDGs – both as outcome of and path to achieving poverty
reduction and sustainable development
• Report of the the SR to UN General assembly “Right to health and SDGs” (2016)
• http://www.ohchr.org/EN/Issues/Health/Pages/SRRightHealthIndex.aspx
• Main issues identified in the report: inequities, accountability, universal health
coverage, violence
• UN Human Rights Council resolution on health and 2030 Agenda (June 2017)
“Leaving no one behind”: it is about non-discrimination and
accountability
• Data collection – identify disparities, disaggregate, use qualitative research
• Agenda 2030 suffers from weak accountability mechanisms
• The need to have a vibrant civil society and to support NGO sector.
• Warning from experts: states need to refrain from a selective approach to right to health and related
human rights. This warning is valid to EU member states as well!
• To learn good lessons (from AIDS movement): health services work only when they are free from
discrimination (by law and practice). Still many discriminatory practices and attitudes in health sector
• To promote knowledge and evidence; to identify and address “fake news” and conspiracy theories of
“post-truth era”
• Globally - attacks against universal human rights principles. Examples – debates about Istanbul
(CoE) convention in Europe, rights of people on the move, “traditional family values”vs. rights of
individual members of family; sexual and reproductive rights, rights of people who use drugs, etc.
Towards Universal health coverage (UHC)
• Many governments are moving ahead to reach UHC soon. Warning from experts:
States must not be tempted by low hanging fruit.
• Focus on addressing financial exclusion and catastrophic spendings should not ignore
important issue of discrimination on other grounds
• Focus on access to essential medicines and vaccines should not ignore other
important interventions, such as psychosocial and population based interventions
• Sexual and reproductive health health/rights, mental health, palliative care are part of
UHC.
• Increasing importance of investing with new quality in mental health. Goal3 in
Agenda 2030 includes mental health.
Mental health - Momentum
• Importance of mental health – increasingly recognized
• Agenda 2030 and SDGs: “to promote mental health and well-being”. Good opportunity to place mental health
from margins to center of health and development agenda globally. UN HRC resolutions (2016, 2017)
• What does it mean “to promote mental health and well-being”? The need to find wise balance, based on values
and evidence, within so many different issues and approaches
• States are urged to invest more in mental healthcare
• How to invest more in mental healthcare services – support them as they are (status quo) or do we need a shift
of paradigm?
• Unacceptable situation with violations of human rights of persons who need and who use mental health services.
Is this just because of lack of resources? Paradox of the European region (largest number in the world of people
living in institutions)
• UN Human Right Council resolutions on mental health and human rights (2016, 2017), reports of OHCHR and
UN Special rapporteur (2017)
• All stakeholders should rethink their position on mental health policies and services
To promote mental health of everyone
• Social and environmental determinants of mental health (including psychosocial/emotional
environment)
• All forms of inequalities and violence have negative impact on mental health
• States need to invest in enabling non-discriminatory and non-violent environments in all settings
(family, school, workplace, community, healthcare services, society at large). All forms of violence are
not acceptable.
• Full implementation of a human rights based approach is an obligatory pre-condition of effectively
investing in mental health (including promotion, prevention, treatment, rehabilitation, recovery)
• Crucial role of civil society – both for advocacy and service provision
Report of the Special rapporteur to UN Human Rights Council on mental
health and human rights – June 2017
• Global burden of obstacles highlighted – as an alternative view
to the medicalized concept of “global burden of diseases”
• Three main groups of obstacles identified. They need to be
seriously addressed:
- Dominance of biomedical model and overuse of biomedical
interventions
- Huge power asymmetries
- Biased use of knowledge and evidence
Report to UN HRC - key messages and
recommendations• Ensure that users are involved in the design, implementation, delivery and evaluation of mental health services,
systems and policies;
• Stop directing investments to institutional care and redirect it to community-based services;
• Invest in psychosocial services that are integrated into primary care and community services to empower users
and respect their autonomy;
• Scale up investment in alternative mental health services and support models;
• Develop a basic package of appropriate, acceptable (including culturally) and high-quality psychosocial
interventions as a core component of universal health coverage;
• Take targeted, concrete measures to radically reduce medical coercion and facilitate the move towards an end to
all forced psychiatric treatment and confinement;
• Seek technical assistance from the WHO QualityRights initiative to assess and improve the quality of mental
health care.
Mental health policies/services: urgent need for the shift of
paradigm
• Human rights imperative
• Address adversities in childhood and adolescence
• Prevent medicalization of human diversity and misery
• Mainstream mental health and discontinue investments in segregated psychiatric
institutions (also when providing international assistance)
• Prioritize culturally appropriate psychosocial interventions
• Replicate good practices that provide non-coercive mental health services
• Address imbalances and biased knowledge in medical (health related) education and
research
Some SDGs-related recommendations
(from SR report to UN GA, 2016)
• Identify disparities and prioritize the most vulnerable through collection and disaggregation of data,
using quantitative and qualitative data
• Ensure full compliance with universal human rights principles and refrain from selective approaches
to upholding the right to health and other human rights when implementing the SDGs
• Monitor progress and support review and accountability in the implementation of the SDGs
• Empower all stakeholders to participate in the design, implementation and monitoring of laws,
policies, practices
• Ensure that healthcare systems are effective, transparent and accountable, with a focus on primary
health care and health promotion
• Address imbalances and power asymmetries within and beyond healthcare systems in all decisions
aimed at reaching UHC
Conclusion
• Member states are in a good position to advance with realization of the right to
physical and mental health and to strengthen healthcare systems in the framework of
Agenda 2030
• To achieve this, universal human rights principles, enshrined in the UHRD and UN
Conventions, need to be fully implemented, in synergy with modern knowledge and
evidence on health-related issues.
• States, in partnership with civil society, should advance with mental health and
human rights - keeping in mind that human rights based approach and modern
public health approach are the most effective “vaccines” in reaching healthy,
inclusive, efficient and tolerant societies.
Daniel Chisholm, Programme Manager for Mental Health
WHO Regional Office for Europe
Public mental health
and the
sustainable development agenda
Dr Dan Chisholm
Programme Manager for Mental Health WHO Regional Office for Europe
Copenhagen, Denmark
Mental health as a public health and development concern
Public health
o Mental ill-health leads to impaired
functioning; depression is the No. 1
cause of global disability
o Mental health problems are often
comorbid with physical health
problems, which adversely affects
treatment outcomes (e.g. CVD)
o Mental illness & substance abuse
affects others – e.g. infants of
depressed mothers; family
members of dependent drug or
alcohol users
Sustainable development
o Mental ill-health results in enormous
economic loss; depression & anxiety
cost the world US$ 1 trillion per year.
o Mental illness is strongly associated
with poverty, economic downturn and
unemployment, with effects felt most
by the most vulnerable
o Mental health is put at greatly
increased risk by natural disasters,
disease outbreaks, communal
violence, conflict and forced migration.
03.05.2018 51
Mental health and the SDGs
• Target 3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being
• Target 3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
• Target 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all
But what about the social determinants of
mental health?
Source: Lund et al (2018) Social determinants of mental disorders and the sustainable development goals: a systematic review of reviews. Lancet Psychiatry.
Demographic domain
Gender
• Females: increased risk for
depression, anxiety, eating
disorders
• Males: increased risk for
substance abuse, childhood
behavioural & developmental
disorders, and suicide
Age
• Most mental disorders start early
in life
• Early intervention essential
• Key risk periods over life-course:
– Pregnancy
– Early childhood
– Adolescence
– Old age
Social domain
• Examples: – Education– Family and peer relationships– Social capital– Social networks – Cultural identity
• Low education: increased risk for dementia, common mental disorders, chronic stress
• Social capital and social support: protection against common mental disorders
Economic domain
• Income & expenditure
• Financial strain & debt
• Food security
• Employment
• Housing
• Income inequality
• Macroeconomic trends, e.g. recession
Mental health and inequality
1. For individual level data, the picture is clear:
– Inequality is associated with worse mental health for people in lower socio-
economic positions
2. For national level data, findings are mixed:
– For some high income countries there is a clear linear association: increased
inequality is associated with increased mental illness
– But for a larger group of low, middle and high income countries, the trend is
less clear
– Possible explanation: “Income inequality hypothesis” – beyond a certain
level of income, inequality becomes more important in explaining mental
health disparities 1
1 Layte, R. (2011). The Association Between Income Inequality and Mental
Health: Testing Status Anxiety, Social Capital, and Neo-Materialist Explanations.
Eur Sociol Rev 28 (4): 498-511.
Neighbourhood domain
• Constellations of area-level environmental risk factors:
neighbourhood level deprivation, access to recreational
facilities and service availability
• Neighbourhood socioeconomic deprivation associated
with psychosis, depression, common mental disorders in
young people, worse cognitive function in older adults
• More life stressors, fewer resources to cope
Environmental domain
• Disasters and hazards:
– PTSD, depression and anxiety
– 3-4 times higher prevalence
• War and conflict:
– Behavioural & emotional symptoms, sleep problems and psychosomatic symptoms common among exposed children
– Meta-analysis of prevalence of child PTSD in conflict: 47%
Measurement challenges and needs in the SDG era
• The ‘promotion of mental health and well-being’
(SDG target 3.4)
• Universal health coverage for persons with mental disorders
(SDG target 3.8)
• The social determinants of mental health
(other, ‘non-health’ SDGs)
Conclusion: The SDG Challenge
• How do we demonstrate the link between attaining
“upstream” SDGs and mental health benefits?
• Can we also show that providing mental health care yields
economic and environmental benefits?
• Is mental health both a means and an end of development?
Conclusion: key messages
1. Social and economic factors are powerful determinants of population mental health
2. There is sufficient evidence to invest and scale up broad-based multisectoral interventions that address the causes and consequences of mental illness
3. Further research is required:
– To identify pathways, especially in relation to inequality
– To evaluate interventions that address both social causation and social drift
WHO Europe – mental health and SDGs factsheethttp://www.euro.who.int/en/health-topics/noncommunicable-diseases/mental-
health/publications/2016/fact-sheets-on-sustainable-development-goals-sdgs-health-
targets-mental-health-sdg-target-3.4